The Old Vicarage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating changed to requires improvement. This meant people were not always completely safe and protected from avoidable harm. A breach was identified at this inspection in relation to the management and mitigation of risk.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We identified that staff had not always reported accidents and incidents fully. This meant it was difficult for the management team to carry out an effective analysis or learn lessons from incidents to prevent reoccurrence. The registered manager acknowledged the finding and told us they would take action to improve this.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff referred people to appropriate specialist teams when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe from harm and abuse. Safeguarding processes were in place to record concerns and notification to the local authority and CQC were made appropriately.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place, but they did not always include appropriate mitigation or actions taken to reduce risks. Some information was generic which meant the mitigation was not person-centred. Other information was incorrect such as suggesting a person was not at risk of falls due to requiring support with a hoist, when they were in fact independent in moving about the service.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had not identified issues with window safety until an incident had occurred. Since the incident the provider had taken action to improve window safety throughout the service.

The environment was pleasant and homely; people were able to make use of the garden and sitting rooms.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were safe with a good skill mix per shift. There were processes in place to safely care for people in the event of staff absences. Staff were recruited safely, in line with best practice guidance.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Personal protective equipment (PPE) was made available to staff for when required and there was plenty of PPE stations throughout the service. Staff had received infection prevention and control training. The service was clean and tidy.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had an electronic medicines administration system which helped ensure medicines were administered safely. Staff competencies were regularly checked, and training was up to date. Medicines storage temperatures sometimes exceeded the recommended maximum in the treatment room, however plans were in place to make changes to the treatment room and improve this known issue.